Diabetes nurse consultant Ruth Miller knows only too well that people with diabetes are dying because of a lack of knowledge among healthcare professionals.

Ms Miller, who works for NHS North West London Collaboration of Clinical Commissioning Groups, recalls the inquest of a young woman, who presented at an emergency department disorientated and with unexplained injuries.

The woman had type 1 diabetes and schizophrenia. She was admitted under the care of a mental health team, but was not referred to specialists in diabetes. After returning home, she was found dead, having had a hypoglycaemic episode.

‘She had been running her glucose low because of her anxiety about developing complications,’ says Ms Miller. ‘If the emergency department had let us know, we may have been able to help her.

‘Nocturnal hypoglycaemia was actually written in her notes. She had classic symptoms, but the diabetes team was not made aware.’

This is not the only case Ms Miller is aware of where a person with diabetes has not received appropriate care, with tragic results.

Core competencies

Using her experience as the clinical lead for diabetes, Ms Miller developed and piloted Diabetes 10 Point Training, a resource for healthcare professionals caring for people with diabetes, based on the most commonly seen errors.

‘Having experience in leading transformation projects by standardising practice, I knew the importance of training to ensure staff possess core competencies,’ she adds.

‘The inquest was shocking and I noticed the same mistakes being repeated,’ says Ms Miller. ‘It was not highbrow medicine. The patient had told staff assessing her that she was experiencing nocturnal hypoglycaemia. Hence point one of the training: listen to the person.’

Training

The multidisciplinary training is designed to be brief, relevant and clear, with attendees receiving small aide-memoire cards of the main points. And it is flexible to the needs of clinical areas.

‘The training takes 15 to 30 minutes and is offered at ward level to increase uptake. Teaching is adjusted to the needs of the group, the location and the time available,’ says Ms Miller.

Evaluation of the training programme showed it improved staff confidence and patient safety.

Participants’ self-reported confidence in 11 domains was assessed immediately before training and three months later, revealing greater confidence in every area after the training.

Small checklist cards of the main points are given out in the training. Picture: Barney Newman

The trust that cared for the woman also moved from the highest quartile for insulin errors to the lowest over a six-month period. Data from the National Diabetes Inpatient Audit, which covers hospital trusts in England and Wales, show a drop in insulin errors from 25% to 13% and in prescription errors from 39% to 15%.

The programme has been such a success that it has been developed for and implemented in mental health settings in north west London.

Need for change

Ms Miller notes that, as the prevalence of diabetes is increasing, so are the numbers of patients coming through all services and settings. This, she says, presents a significant challenge for staff education across the patient pathway.

The ten-point training tool is endorsed by Diabetes UK as an example of good practice.

‘Diabetes is extremely complex and most people working on mental health wards are not specialists, but everyone needs to have basic knowledge,’ says Diabetes UK programme manager for inpatient care Emily Watts.

‘Basic diabetes knowledge is not always being achieved through training, which is concerning. We are talking about healthcare professionals not knowing the difference between type 1 and type 2 diabetes’

Emily Watts, Diabetes UK

‘This is not always happening through training, which is concerning. We are talking about healthcare professionals not knowing the difference between type 1 and type 2 diabetes.'

‘Rather than putting on once-a-year training, this training is offered by the bedside, and they receive a card reminding them of what they must know,’ Ms Watts adds.

‘Importantly, the training can be made specific to areas.’

Ruth Miller goes through her diabetes training with two colleaguesPicture: Barney Newman

Clarity and simplicity

In her current role, Ms Miller is implementing the training in mental health settings across north west London, but has also worked with the clinical director of St Andrew’s Healthcare, a charity based in Northampton with 800 inpatient beds for people with mental illness.

The organisation cares for some of the most clinically complex patients in the mental healthcare system, many of whom could not be treated elsewhere (see box).

Ms Miller says this work is timely because people with diabetes and mental illness have worse outcomes for the two conditions; 15% of people with serious mental illness have diabetes yet up to 70% are undiagnosed, with life expectancy reduced by up to 20 years as a result.

‘The tool has made a real difference to nursing practice and I have big ambitions to improve nursing care on a larger scale,’ she adds.

‘It is important to ensure the integrity of the model is maintained so I am working on a train the trainer programme.

‘We are also working on developing an online module of the Diabetes 10 Point Training programmes to ensure training can be accessed by as many patient-facing staff as possible.’

‘We wanted to achieve parity of esteem between mental and physical health’

One trust that has adopted the ten-point training is the 800-bed charity St Andrew's Healthcare, in Northampton.

‘While we were doing well with mental health outcomes, physical health outcomes were clearly different across the board,’ says the clinical director Vishelle Kamath.

‘There was clearly a deficit. We wanted to ensure there was parity of esteem between mental and physical health.’

The charity decided to carry out an audit of its population. It reflected national research showing that people with mental ill health are two to three times more likely to develop diabetes because of poor diet and obesity, lack of physical activity and as a result of antipsychotic medication.

‘While going through that process to improve care and monitoring, we realised that one of the deficits was the knowledge of our staff’

‘We began to look at how we set out a clear diabetes pathway,’ says Ms Kamath. ‘While going through that process to improve care and monitoring, we realised that one of the deficits was the knowledge of our staff.'

Suitable training option

Ms Kamath had reviewed a number of different training options before the charity learned of the ten-point training tool through Diabetes UK. At that point Ms Miller was looking to develop it for mental healthcare.

‘We chose it as it was easy to translate and adapt, concise, and the training can be delivered in smaller groups or on wards,’ says Ms Kamath.

‘With Ms Miller, we have been able to adapt it to each area. We have a range of patients, including people with long-term brain injuries and Huntington’s disease. Some patients stay with us for a long time and some staff need to have more detailed information.’

‘The staff reported that they found the ten-point training plan useful as it is easy to follow’

The training was trialled with the whole ward team.

‘The staff reported that they found it useful as it can be delivered in short spaces of time and is easy to follow.

‘We looked at how staff felt about their knowledge before the training and we are hoping to see the same outcomes as Ruth has in inpatient and community settings.’

Roll out

The charity is rolling out the Diabetes 10 Point Training tool throughout the organisation.

For the nursing team, it has been modified for registered and non-registered staff.

Registered nurses had more information about medication. Their feedback included: ‘The management of insulin was clear and easy to pass on and hand over’ and ‘It was easy to follow in relation to insulin dosage’.

Non-registered staff also found it easy to understand and, as well as boosting their knowledge, it had an unexpected benefit in terms of their morale. Comments included: ‘For once it felt like we were in the teams’ and ‘With the training, I am so much more aware of my patients’ health’.

‘This is important,’ Ms Kamath adds. ‘These members of the team spend a lot of time interacting with our patients and they play a large role around meals, eating and patient food choices.’